Patient Care Preparation

Additional Info

• Audio File:uab/ua166.mp3
• Doctors:Mullins, Haddon;Willig, James
• Featured Speaker:Haddon Mullins, MD | James Willig, MD, MSPH
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4355
• Guest Bio:Haddon Mullins, MD is a General Surgery Resident. 
  
  James H. Willig, MD, MSPH, is the Associate Dean of Clinical Education in the School of Medicine. He attended Medical School at the Instituto Tecnologico de Santo Domingo (INTEC) and completed his residency at the University of Virginia Roanoke-Salem. At UAB, Willig has earned an M.S. in Public Health and completed an Infectious Diseases Fellowship. 
  
  
  Learn more about James Willig, MD, MSPH 
  
  Release Date: November 9, 2020
  Expiration Date: November 9, 2023
  
  Disclosure Information:
  
  Planners:
  James Willig, MD, MSPH
  Professor, Infectious Diseases
  
  C. Haddon Mullins, IV, BS, BA
  UAB Medicine
  
  Jill Deaver, MA, MLIS
  UAB Medicine
  
  Adam Roderick, M.ED.
  UAB Medicine
  
  Anne Zinski, PhD
  UAB Medicine
  
  Caroline Harada, MD
  Associate Professor, Geriatric Medicine
  
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Presenter:
  James Willig, MD, MSPH
  Professor, Infectious Diseases
  
  Dr. Willig have no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Melanie Cole (Host):  Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing patient care preparation. In this panel, are Dr. James Willig. He’s the Assistant Dean of Clinical Education at UAB Medicine and Dr. Haddon Mullins, He’s a General Surgery Resident at UAB Medicine.
  
  Haddon Mullins, MD (Guest):  Hello and welcome to evidence-based teaching with the two of us, Haddon Mullins and Dr. James Willig.
  
  James Willig, MD, MSPH (Guest):  Good morning Haddon. How are you today?
  
  Dr. Mullins:  Do well, how are you?
  
  Dr. Willig:  Fantastic. Fantastic. What do got for us today?
  
  Dr. Mullins:  So, I’m speaking to the introduction to what we’re going to be covering, mainly focusing on bedside teaching. This week, we’re going to talk about preparation. So, everything we’re going to talk about today will be before you actually go into the room with a patient and things you can do to best prepare yourself, and your entire team for that encounter.
  
  So, from looking at the literature, a lot of people believe that one single meeting or an orientation with your entire team can be extremely beneficial for you, the team and the patient. And so this is something that as an Attending or as a team, you would only have to do once and would help set expectations, allocate roles, and allow you to better assess and get feedback to your entire team. So, really this would be something that you could or should do at the beginning of each clerkship when you have either new students, new interns, new residents or you are coming on to service for the first time.
  
  Dr. Willig:  So, it’s sort of a team specific orientation?
  
  Dr. Mullins:  Yes. It’s very important that the entire team is present for this. Because the entire team is involved in patient care. The entire team is involved in feedback and assessment of each other and the entire team should be aware of what roles are assigned to each team member to better facilitate communication and patient care as well. Is a meeting at the beginning of a rotation, is that something that you do or is that commonly done among Attendings and if so, how long does it take and what do you cover?
  
  Dr. Willig:  So, I think it’s something that I’ve certainly learned or was taught to do it by my senior residents. Even as a resident, stepping into a team. And initially, when I was an Attending, I didn’t really think about doing it but very quickly sort of realized that I’d better make – have a good conversation, level-setting conversation with the team in general and then I also do something with the resident in particular where I will ask the resident some about how they like to run the team, how I will empower them to run the team. I think that they are central to the teaching climate and I want to see how they interact and how they lead to interns and the students. I will speak the resident about what are their preferences regarding rounding. I have some preferences; they have some preferences. From preferences, we’ll try and negotiate those to arrive at a mutually convenient solution and I will let them know that I for example, like to round the day of call in the afternoon on a few patients to make the load post call less so. But I want to do that in a respectful way to the resident where I will tell him, heh try to get some cases already done and discussed with the interns or the students and when I come by in the afternoon, you tell me which cases to discuss. And they will be cases where you already have discussed the plan with them. So I’ll go over the plan. I’ll see the patient with them independent of you. You need to go see other admissions. Eventually, I will circle back to you and present what I think should be done differently or added to the management or just confirm that heh, your management is on point, I like what you’re doing. Let’s keep going.
  
  But certainly, if you don’t negotiate that with the resident, if you don’t let him feel empowered to lead the team; I think it takes away from the learning.
  
  Dr. Mullins:  That’s great. And you can talk a little bit more later about the resident impact on teaching and how important they are in a role to the teaching experience. But what about students? Do you orient the students at all or give them a plan or a set of expectations?
  
  Dr. Willig:  So actually, so I have a general set of expectations that I share with everyone. And I’ve got a copy of the document here. The document really has twelve general points and it’s got sort of three specific rules of thumb. So, these twelve general points, to me, the reason I share this is I want students and house staff to both know exactly where I’m coming from. These are the things that I think about how we should – the standard that we should hold our care to. So, I’ll go over these things. At the same time, I will also point out that the expectations are different. I will point out to the students that though they will see the interns and the resident seeing cases very quickly; that they at this point in their training, they are honing their efficiency. I think our students get a little bit anxious when they see how fast the residents and the interns can do things. And they begin to try to learn how to do those things equally fast.
  
  There’s a problem there because the student is at the point in their training when they really have to be focusing on building the basic skill set, the basic habits on top of which they will do further refinement towards efficiency in those subsequent years of their training. But now, at this point in your training, you are training for thoroughness, completeness, reproducibility. Those are the things that are emphasized, and I mention those things out loud to the students to give them permission to take your time. Don’t go in there with the resident and the intern every time and try to leave when they leave. Sometimes, let them go independent of you. Then go subsequently. Spend an hour, an hour and a half, whatever you need to spend with that patient and then go ahead and write your not independently. And then go discuss your plan with the intern and subsequently the resident or both of them together.
  
  But you have to do these things by yourself. You have to walk in there and you have to know that gosh, I’m going to inspect, palpate, percuss and auscultate every organ system. Those are the things that as a student, frankly, you’re going to be tested on, on your step two CS. You’re not going to be tested on how quickly you can get to the diagnosis or the efficiency with which you go through all of those things. Those things are part of it, yes. But the completeness, the maneuvers being high quality and being reproducible; that’s what the students should focus on.
  
  So, I make that plan that my expectation for them is completeness and thoroughness. With the interns and the residents, now we talk about having a different conversation. With them, I’m expecting more – I’m expecting the resident to be my partner in management. I’m expecting that the resident and I will have conversations really about here’s what the literature says about this, here’s the last time I read about this topic, this was a recommended therapy. What do you recommend?
  
  With the interns, I tell them that I want them to be involved in management. That I expect their exams to be thorough, but they can be more focused than what I’ll expect the students to be. So, they can focus on efficiency and getting the repetitions in to increase that. But I tell them that everything that they mention, they have to have a rationale for in terms of management. If someone says to me, I want to get a CAT scan. Well precisely why? Why are you doing that? What’s your rationale? And I let them know that I will challenge your rationale not because I’m trying to disagree with it or pick at it, you just have to have a logical path. So, you have to be able to tell, I’m doing this test to differentiate these two conditions, and this is how I think it will help me.
  
  So, every single on of our decisions has an underlying logic to it. And I’m going to pull out the strings of their logic to see if I see any flaws or things that I can focus on to improve on. So, those in essence, are the three sets of expectations and in this meeting, really letting people know this is what I’m looking for in you. This is where you are in your training. Again, highlighting these expectations to the students in their first day. This is what I expect for you with your interaction with patients. And this is what I expect from you in terms of your documentation and highlighting how they are different from my expectations for the residents and the interns I think empowers the students to really focus on what they should be focusing on at this point in their training.
  
  Dr. Mullins:  So, what about the difference between a third year medical student on his first rotation versus on his last rotation? Is there a difference in expectations and assessment? It is largely the same?
  
  Dr. Willig:  I think my expectation would be – I would be much more permissive in terms of gosh this differential didn’t really go in depth with someone at the beginning. The expectations really are the same. I really think that in that third year, the things that we’ve already discussed is what they should be focusing on. And I expect to see an increase in skill and refinement as the year goes by. So, if I were to see a student who comes in and in their first rotation is already showing me that their skills are very refined; that’s great then I can start focusing their teaching goals by talking about I want you to get a little bit better at – read more about your differentials, read more about your plans. I can certainly move them down the chain.
  
  But if it’s late in the year and somebody comes in and they don’t have a good grasp of a thorough history and physical; then I think that’s a more problematic student for me. That’s a student where we have to kind of go in and say heh, let’s deconstruct some of these almost shortcuts that you’ve learned throughout the year and you’ve been giving a lot of value to these things and it’s right, they do have a lot of value, but they are going to have more value if you build them on a strong foundation of being thorough.
  
  So, those are the – in general, I think my expectation is for that student towards the end is a little bit more refined because they’ve had more repetitions. They’ve worked through their technique. But sometimes at the end, you get a student who maybe did not receive permission to focus on the basics at the beginning or along the way and what they focused on is on learning the efficiency shortcuts that the residents and the attendings themselves that they’ve seen them use. And all of the sudden, you have a student wanting to run before they can walk. And so much of medicine is just thoroughness and being meticulous. And I think you’ve got to have that. So, with those students, then the conversation becomes take it back, take it back. I need you to be thorough and meticulous. This is where you are in your training. You can’t have shortcuts on a very thin base. The broader your base, the better your shortcuts, the more higher quality of your care subsequently.
  
  Dr. Mullins:  One thing that the literature seems to emphasize is to set your expectations and set your objectives but also to get the objectives from the students as well. What have you already accomplished? And where are you trying to go? And so, again, having the whole team there, everybody is aware of where the student is trying to go, what they are trying to learn, what they have already been through. So, they’ve already been through internal, OB-GYN and now they are on their surgery rotation. Everybody knows what that student should be expected to know how to do and what their primary goals and what their primary focus should be for this rotation.
  
  Dr. Willig:  I think that’s a very important point that knowing where your learner is, so that you can build from the level where they are at is a critical part of this. And I’m glad that the literature reflects that because certainly, I think some of the most skilled educators that I’ve interacted with over the years, they really start with some questions to sort of figure out where your level is and then they build on that. And that’s fantastic. I think in learning theory, that’s part of constructivism I think it’s called but I would have to check with Dr. Zinski.
  
  Dr. Mullins:  Yes, constructivism or adult learning theory is as some people might call it. and I think that’s a good point to make because it – I can see it alleviating a lot of frustration between the team and student. You can get students at different levels that have different expectations and it would only take a couple of minutes, a couple of probing questions to figure out where they stand, what they feel comfortable doing and how to build on that.
  
  Dr. Willig:  And you reminded me of some interactions with – I was fortunate to have a great resident on the first rotation I ever had as an intern in internal medicine. And her name was [Lana Nicotina 00:13:10]. She’s a cardiologist now. And I remember Lana sat me down and she said the first time – if you are doing something for the first time, you’ve got to tell me so that I can do it with you. The second time, I will expect you to try to do it alone, but you call me in to double check. And the third time, go read about it. So, she was pretty hardcore, but it made it clear that the expectation was that if she was asking me to do something I had never done before, that she was at fault. And that the only way that she would know that would be if I spoke up. And you’re right, that alleviated frankly a lot of fear for me as sort of a newly minted intern that I knew that heh, my resident doesn’t expect me to just know things. They want to help me, but I need to tell them I need help when I do. And that was a fantastic thing.
  
  Another thing I can recall, is one of the residents that I worked for, that I worked with for the last couple of years, would – will ask the students heh, name three topics that you want to learn more about while you’re here. And that first day, all the interns and all the residents and the attending and the students will get to write three topics on the board and then our goal is to cross through all those topics as we go through the next couple of weeks working together. And that’s sort of a nice way for everybody to sort of say, heh, I don’t know everything. Here’s some things that I could really use a review on. So, I think it’s great to see that your attending doesn’t know everything, your resident doesn’t know everything, your interns nor your students know everything. Here’s some tangible evidence of that that we’ve all written on the board. And this is how we’re going to make each other better over the coming weeks.
  
  Dr. Mullins:  Yeah, I think that plays into another topic that’s emphasized in the literature is to create a safe learning environment and to emphasize how you’re going to teach and we talked about expectations but also, things like for students that may be just coming on at the wards, we do bedside rounds, I’m going to ask you  questions. I’m going to ask the interns questions. I’m going to ask the residents questions and those questions will be graded based on what their expectations are and what their objectives are and the example that you gave, don’t be afraid to ask questions yourself and set an environment that we are here to learn, you are here to learn. And these are the ways in which we are going to do that is important especially for students I think but also for the interns and residents and we’ll get to the resident side of things in just a second. Because they are a key part in all of this.
  
  But discussing the learning environment and what kind of environment that is going to be is as important as the execution of that.
  
  Dr. Willig:  I think that’s great. Two points that I make in this sheet that I give them on the first day is I talk about the authority gradient. And I first learned about this concept reading about errors in the airline industry. And one specific type of accident that was called controlled flight into terrain. So, this is from a great book called, “Why We Make Mistakes” where they – to sort of summarize, there would be – despite all the advances in technology for about 30 years, this is leading into the 80s in the airline industry, there was one category of accident that never changed. And that category of accident was a controlled flight into terrain. Which basically worked out something I was the pilot, and I was driving this plane and you were the co-pilot and you were checking the altitude and you were like ah, you know we are in this mountain range, the mountains typically aren’t this high, I think we are a little bit low based on the altimeter and I would look at you and say something like look, I’m the senior pilot here, I’ve been doing this for longer than – for ten years. I been doing this when you were in high school, leave me alone, I know what I’m doing.
  
  And that plane would inevitably sort of clips it’s wing on the peak and a lot of people would die because of what basically is arrogance. So, this authority gradient where we look at people with – who have achieved the different rank and we view them differently or more capable than other ones is a double edged sword. It can hurt us. And it can hurt the people we care for as well. So, when you fly to the authority gradient, when you say on the first day things like you know we have to all engage in the care of this patient, all of us working together is going to find a better solution than any one of us working alone and I explicitly give – this is sort of a sense that I’m reading from this document, is I respect and want to hear your opinion, particularly if it disagrees with mine. To give our best to the patient, we have to create that learning climate where there’s a give and take and we are all working together for the benefit of that case.
  
  Because the best ideas that I’ve seen, are rarely from just one mind. The best ideas are this amalgam where it’s 10% from your mind, 50% from someone else’s mind, 5% from my mind and so forth through the team and then collectively through discussion, we’re able to really iterate on an idea, get it to another level and that is our best as a team. Teams that function that way, I think provide excellent care, are immensely satisfying and empowering to all team members. I’ll tell the students; I’ll ask them questions. I’ll say, look, you know I’m an infectious disease guy. So, when do you think was the last time, I read about say hypothyroidism? And they say I don’t know. I say well I probably read about hypothyroidism last when I was recertifying for my internal medicine boards, four or five years ago. When was the last time you read about hypothyroidism? And they read about hypothyroidism within the last six months usually.
  
  And I’ll say who do think has more up to date and better information to offer that patient about hypothyroidism? He says you got more book knowledge than I do. I might have seen a few cases. But the – so I have some insight too. But the best thing we can offer that patient is if you and I have a collegial respectful conversation and the best of what we both know combines into a treatment plan. Now we’re getting somewhere. Now we’re doing something that neither one of us could do independently and we’re both putting our best on the table in service of that patient. So, I love teams like that. And I haven’t always worked in teams like that. And part of the reason why I write specifically about the authority gradient and my fourth point which is you have to nurture your humility where I specifically talk about that certainty is an enemy in our profession. It leads to premature closure and a parochial view of possibilities, so you have to stay humble because those who are humble, they listen a little better, their hearing is a little better. Their vision is a little better.
  
  And they are able to ask questions to enlist better responses. The minute you get overconfident in our line of work, is the minute that your senses dull a little bit. So, I think that that teaching climate to me, taking that evidence on the authority gradient from the airline industry experiences that when they really changed the culture around the cockpits, then that type of accident started to really change where everybody was empowered to say heh, wait a minute. Those ideas by themselves in our profession now, in the ICU for example. When someone is doing a procedure, anybody in the procedure team can call a time out. In the OR, these sort of team dynamics have found themselves and been infused into our profession as well and a lot of it is learning from the airline industry on how teams should function and how every team member should be empowered and how that leads to better outcomes.
  
  And the point about humility I think is more of a personal point and I think basically, I think all our students are going to do amazing things. But the minute you start believing that you’re amazing as well, it’s a problem for everybody who depends on you for care. Because that’s the moment where you probably don’t see as clearly, listen as well and things will get missed because when humility hardens into arrogance, that intransigence does not help get good outcomes. So, those things are part of the learning climate and I think highlighting that to learners, you’ve got to be humble and it’s your responsibility to remain humble and to check yourself and as a team, there is no authority gradient here. None of us is the smartest person in the room. All of us, together, that is the smartest way to provide care.
  
  Dr. Mullins:  And I think that’s key and that’s exactly what’s reflected in the literature and within that context, of the learning climate, and the authority gradient; is a good placement to move and to role allocation. And we’ve talked about role allocation some already and the expectations for students and interns and residents. So, we will mislead the rhyme pneumonic in the slides at the end. But I think one key aspect to highlight especially during this meeting with the whole team; is that the resident should be treated with the same authority as an attending. And that they should be seen as a teacher just as the attending is. There’s a lot of people that are doing research in peer to peer education or near peer education so interns as teachers and residents as teachers.
  
  There’s a study [00:22:58] 2001, and they did a lot of analysis as to what can predict clerkship grades. But they not only did clerkship grades, they did student grades and they did a number of parameters. They gave a pre-clerkship test and a post-clerkship test. They used grades. They used standardized test scores. A lot of things went into how they – into what they called student growth. But one thing that had the most effect on student growth was the residents. And that had the most predictability in terms of how that student was going to grow across the clerkship was the residents.
  
  And so, the residents need to be viewed as educators and they need to view themselves as educators and they are – yes they are learning from the attending on how to do that, but as far as the student is concerned, and as far as the interns and the team is concerned; I think it’s important that they be viewed in that light as that’s what they are aspiring to be and so that’s how they should be treated.
  
  Dr. Willig:  To be honest with you Haddon, the way that I see it is, I got something to learn from everybody. Everybody on that team has read something more recently than I did. So, I think everybody on that team is empowered to make each other better. I sort of was chuckling thinking back to a gentleman that I worked with many years back called William Irwin and he really – his first day, he’d sit you down and it was a very brief meeting because Irwin had three basic rules. The first rule was we teach each other something every day. I love that rule because it really meant that we had the responsibility to make each other better every day. And that meant that some days he was going to teach, some days the resident was going to teach, some days the intern was going to teach, some days, the student was going to teach. But everyone of us had a collective responsibility to sharpen each other every day in the practice of our craft.
  
  That was his first rule. His second rule was we give every patient our absolute best. Some people say this as we treat every patient as if they were our closest family. Which ever way you say it, everybody deserves your absolute best. Your retention, your focus, your go home and read about it so that you can come back and be more informed about what you are doing the next day. Everybody gets your best, personally, and professionally.
  
  And the last Irwin rule was and we’re never late for lunch. And he would always say this with the most serious look on his face and walk away. And what he was really saying was, we’ve got to be efficient. We’ve got a lot of people to see and we need to distribute our time appropriately so that we can do a great job on all of them. So, let’s get to it. So, it was a very succinct way to envelope all these principles in just those three quick rules.
  
  Dr. Mullins:  And efficiency I think is the key part of this meeting and another important part is that it establishes a baseline for assessment as well from an Attending point of view. You have established with the whole team, these are your expectations, these are your objectives, you give them an opportunity for feedback to say well I don’t feel comfortable with this. I don’t feel comfortable with that. So, you can adjust your level of assessment and your level of expectations for them and if you want to take it the extra mile, you can – the Attending can do like you did and print out a sheet for this and that makes this meeting even more efficient.
  
  But the main point of this whole orientation is to pre-answer questions, pre-address problems so that there on the road, you’re not frustrated, the students aren’t frustrated, and your team isn’t frustrated because nobody is on the same page. And I think these meetings could be done once every two months whenever the students come on board or you’re coming back on service, it would take ten minutes and then it would be done. And everybody would be on the same page. And if you want to print it out, and individualize it, I think that would be even better.
  
  So, now, I would like to bridge the gap between that meeting and then the clinical interaction, the bedside encounter with the patient. And one aspect of that preparation for talking about patients in their care would be the patient. So, is there a patient preparation expectation at an academic hospital like this or is it before bedside rounds or is it well this patient either has been here before and knows about bedside rounds or they’ll figure it out?
  
  Dr. Willig:  So, it’s interesting because I did not used to be very sensitive to this. When I started doing bedside rounds, really as my preferred medium of teaching; I ran into – or I started noticing that people would - sometimes people would be sort of what’s going on. Why are all these people in my room? And some people I would come back in after rounds alone to double check on someone or maybe there was a little piece of history that I couldn’t recall, and I wanted to see if I could delve a little further. But I would find my way back into the rooms. And having good relations with folks, and eventually they’d say man I really like the way you guys do things here. And I remember thinking what do you mean here? this is just – and then that kind of made me think well wait a second. A lot of folks – the majority of folks are probably in private practice. This person has probably never been to an academic medical center before. They are from an area where there isn’t a medical center like this but their options for healthcare are more private in nature. So, I sort of started getting some insight into yeah, not everybody just views it as normal. This is sort of a unique thing where there’s a lot of learners.
  
  So, what I migrated to because I don’t know the person’s experience when they come in. there are sort of a couple of sentences that I try to say to a family and the patient whenever I walk into a room. I find this particularly helpful with families. When you are nervous because your family member is on the bed already and you see one white coat walk in there, you are already a little bit expectant and maybe even anxious. All of the sudden, you see six or seven white coats in there with you. Now you are really not feeling good about things. So, I will usually try to introduce myself, introduce the team, have every person in the team really introduce themselves. I make a point of introducing myself by my first name. that’s just a matter of preference but again, to me, that’s just lowering that authority gradient right away.
  
  I would say something like heh, we like to discuss cases at the bedside. I don’t want you to have to tell your story yet another time. You already told it several times and we really appreciate that. I want to share everything that we know about you for a couple of reasons. The first is our decisions are only going to be as good as the facts that we base those decisions on. So, I need you listening closely to make sure that we got our facts straight. Because if there is anything that we’re talking about that isn’t a fact, please correct this because we need the best facts, we can to provide the best care we can.
  
  Then I’ll transition to say we want you to know everything that we know. So, we discuss things very openly here at the bedside. You’re going to hear us talking to each other and really getting ideas polished up as we exchange them with each other. Everybody is going to contribute. We really believe that none of us is as smart alone as all of us together. Sometimes I’ll joke and I’ll say heh you’ve got the six doctors for the price of one special or sort of if I sort of get a feel for that person’s sense of humor, that might be sort of a joke that I’ll attempt to make.
  
  But really just let people know heh, we’re going to be talking about you and I want you to see what we’re doing. And I want you to see how much everybody in here is invested in doing the best for you and how much we all care. And then the last thing I say is, if we walk out that door, and we haven’t answered all your questions; we haven’t done our job well enough. So, you’ve got to ask anything we didn’t explain correctly or anything that you’d like to touch on again, go ahead and let us know. If we walk out that door and again, we’ve not answered your questions that you have; we’ve not done our job as well as we think it should be done. So speak up.
  
  Dr. Mullins:  That’s perfect. The patient, a lot of times, they can feel uncomfortable and an orientation like that makes them more likely to be involved in their own management. And a couple of key points that line up with that I’ve read in your handout here is to review expectations associated with medical language that lines up with another point is to emphasize that there is a teaching aspect of this encounter as well and so establishing that expectation that we are educating learners here. there will be medical language associated with that and then at the end, if we can’t clarify in a language that you can understand what’s going on and allow you to ask questions based on that language then we have failed at our job. And hopefully, orienting the patient to those expectations makes it more likely for them to clarify their own expectations or to clarify when they feel like they need a better explanation.
  
  Dr. Willig:  And I think this is such an important subtlety because it’s intimidating to see a bunch of us walk into the room and just start talking to you when you’ve never met us. And our colleague J. R Hardig from Med Peds made a point to tech me something that I try to do as regularly as I possibly can and he says that when you finish discussing things, a lot of us say do you have any questions. And that’s fine, but I know that if I get asked do you have any questions after a lecture where I’ve been sort of lazing over, my immediate reflex response is no. Because it’s almost that if I admit that I have questions, maybe I wasn’t listening or I wasn’t paying close enough attention so, sometimes people are reluctant to answer that question.
  
  So the questions he – the way he frames it, he phrases it, he says what questions do you have. So, this a beautiful phrase because it establishes, it sort of presupposes of course you’re going to have questions. We’ve just been talking about you incessantly for ten or fifteen minutes. There are questions. You have them. What questions do you have? And somehow, the intent behind this and that subtle change in phrasing, and he told me, he says you’ll see people feel – people will ask you more questions if you say it this way. And I was kind of skeptical. I don’t think that that few words change will really make a difference. But I really feel anecdotally that it has, and I encourage everybody to try that experiment. To go from do you have any questions with sort of a stern look and looking people in the eye to see what they’re going to say to a much more disarming what questions do you have with a smile and sort of leaning in and it’s of course you have questions is the message that comes across. And just run that experiment. See if you get a feel for a different number of questions that people will ask you.
  
  Dr. Mullins:  And involving the patient is a cornerstone of the whole idea of bedside rounds of course and so, preparing them and being aware of the subtleties, those types of subtleties is important and it’s something I feel like that can be marginalized in the larger context of even everything we’ve talked about today but it’s something that doesn’t take long, doesn’t take a lot of educational insight and it’s simple and it makes the encounter more patient-centered.
  
  Dr. Willig:  Yeah, I think a real benefit that I see to it is that the patient-centeredness of it and when you – there’s so many ways that you show you care. And the more ways that you show you care, and that you’re invested in that person, and that you want to do what you can to help them; those are all building blocks and they build this foundation to where if the situation leads to a very difficult diagnosis and some difficult conversations about what comes next; it’s so much easier to have those conversations if you have already shown that person in multiple layers in this interaction, we care about you. This team cares about you. We’re working for you. We’re attentive to your needs and the needs of your family. You’re the focus of what we’re doing. And then if you have to have a hard discussion, you already have those set in the foundation that’s going to facilitate being able to sit at the bedside, look someone in the eye and have difficult discussions when unfortunately in the business that we’re in, tough things will happen.
  
  Dr. Mullins:  So, we talked about the learner. We talked about the patient. Now the Attending. Is there anything that you do as an Attending to prepare yourself for bedside rounds?
  
  Dr. Willig:  So, I think it’s a combination of things for me. First, just like I saw when I was a student then a resident, you learn as much as from the people around you as you do independently. So again, that’s part of keeping your humility, keeping your eyes open, keeping your ears open, looking for best practices wherever you look. I will literally see students do something that has never occurred to me and I will try to incorporate that. I will see very senior people do things to a level of refinement that I may never reach but that I can aspire to and I can sort of really break down the elements of how they had that interaction.
  
  A couple of months ago, I invited a colleague who had taken care of a woman with HIV for about a couple of decades and this woman had developed an advanced malignancy and we had to have an end of life conversation. And boy, I asked this colleague to come into the room and how she interacted with that lady and that relationship and how she was able to just thread so much caring and respect into delivering those news to me it was – I mean I felt like I should just be taking notes. It was unbelievable. And this is something that I’ve been doing for a long time as well for a couple of decades. And I saw so much. I saw what the other level looks like. So, I think that you learn so much from everything that is around you. And that’s part of the learning you do that you can have as an Attending. Just really look for best practices and practices that you like to avoid everywhere with every interaction with all of your colleagues.
  
  The next level of it is – one of my favorite times is, we’ve seen everybody post-call, I’m alone in a quiet place, preferably my office. I have two screens in front of me and I’m listing my problems and I’m combining them into patterns and I’m trying to think about what this could be and the most optimal diagnosis. One of my favorite moments in the world is when I open up to date on that other screen or some other resource and just in real time, sort of check facts and thread it into my note and sort of bolster my thinking by looking at the evidence at the time that I’m putting my thoughts together. Gosh if – I mean those are golden hours for me. I mean it’s just wonderful.
  
  And as you teach yourself and as you really round out your knowledge about a pattern that you are suspecting; as you look at what your residents and your students thoughts and why they thought it and you look at the evidence that either supports or refutes their logic; that’s a great moment that I very much enjoy. And at the same time, that creates a list of things that I’m going to bring in the next day to either just say well you all are on the right track. Did you also consider these facts that I read. Look at this. I think this even adds more support for your hypothesis. Or, even better, I might say, heh, here’s some other evidence that might take this in a different direction. What are your thoughts on this?
  
  So, that to me, as I’m working on those notes, I’m also making a couple of things, sometimes on a word document and I’m dropping phrases in there, these are things that I want to do or sometimes I might print out an article that we’re going to bring the next day that’s centered around a certain patient. The other thing that I’ll do is when I’m on rounds, again, we each have the responsibility to make each other sharper so it might be heh, I need team member X, tomorrow you are going to have three minutes to teach us about this particular thing here. So, look at the evidence, come back because tomorrow we are going to make a decision based on the evidence that you look up. That’s a great thing to do with a student. That sort of says and you incorporate them, and you make that decision with them at the bedside or you get to that point the next day, you basically say okay, what did we learn about this? Student steps in, says what they found our about it, it’s the evidence. What’s your recommendation? I recommend we should do this test, and this is why. Okay. Look around the room, all of us are fine. Okay. All right. That’s the move we’re going to make.
  
  That student just like saw their effort, time just – in the teaching, in the decision an actual patient management decision and they’re enthusiasm will now be through the roof. Then they’ll be doing that without you asking them to do it for the rest of the rotation and they’ll be engaged at a different level. So, that’s part of that learning is sort of putting those people, putting somebody, keying somebody up for a decision every day. And then also as an Attending, you got to take your turn in that rotation. And so there will be someday where you will – you might notice a physical exam finding or someone might mention a physical exam finding for example that I’m not – I said well I need to brush up on that sign. I haven’t done it in a while. So, I might go, and I might read it and then I might ask someone the next morning to heh, demonstrate this, let me give you some feedback on your technique.
  
  So, there will be little spot checks that I’ll do just to kind of take my spot in that rotation to keep the learning going, a team but I give that sort of responsibility that moves around every day then there’s specific things focused on the management of a patient that I’ll be reading on and brushing my knowledge up on that I’ll bring in for a discussion the next day. But those are the basic things I think about how I prepare for rounds.
  
  Dr. Mullins:  And what you described is a perfect combination of what I found in terms of they disease specific review and patient specific and if you can combine those things then even better. The whole goal of it is to create teaching points ahead of time as you do to incorporate the entire team. I see the apex of all of this and one point that a piece of old literature from 1993 comments on is to be aware when you are walking into the room of the conflicts of interest between the students or the learners, yourself and the patient. Because each of you all have in the context and everything we’ve talked about today, each person has different expectations, different objectives, and a different way of assessing those criteria. And for you to have a scaffolding of how this interaction is going to go, and being aware of what the patient wants out of this and what the student wants out of this and what you want out of this, you can better manage that situation as a whole and you feel prepared for what we will talk about in our next session the encounter with the patient.
  
  Dr. Willig:  Excellent. Well thank you. This has been an enlightening chat as usual. It’s great to learn about these evidence based practices and how to maximize the effectiveness of what we do on the wards.
  
  Dr. Mullins:  Yes sir. Thank you.
  
  Host:  And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.
• Hosts:Melanie Cole, MS